ACADEMY of MEDICAL INFRARED
TRAINING
ThermoDoc® Network
ACADEMY of MEDICAL INFRARED TRAINING
ThermoDoc® Network
REGISTRATION FORM
Next Program
September 23 -26, 2010
Breast and Neuro-musculo-skeletal
Program
All registrations must be received by September 10, 2010
Please complete this form and return with payment to the above address.
Make check payable to William Cockburn, DC, FIACT, FABFE
A $250.00 non refundable fee will be applied per applicant for all
cancellations
NAME: __________________________________
Degree: __________
CLINIC NAME: _______________________________________________________
ADDRESS:____________________________________________________________
CITY/STATE/ZIP:______________________________________________________
PHONE: _______________________________________________________________
E-MAIL: _______________________________________________________________
NUMBER OF YEARS IN THERMAL IMAGING: _________________________
TYPE OF EQUIPMENT YOU USE: ____________________________________
LEVEL OF INTEREST IN COMPLETING DIPLOMATE STATUS IN DVD
BASED MODULES: ___________________________________________________
Membership in Thermography Organizations:
_________________________________________________
Page One of Two
ACADEMY of MEDICAL
INFRARED TRAINING
ThermoDoc® Network
REGISTRATION FORM
Po Box 2382
Whittier, CA 90610-2382
(562) 699-7921 Fax- (562) 695-2439
• Two and Four Day Programs
Next Program
September 23 -26, 2010
Two Day Program (Breast )Thursday - Friday) or Musculo-Skeletal/Pain
(Sat - Sun) Please Select One:_____________
Initial Attendee $1,800.00 $______________
Additional Attendee(s) $900.00 X ___ $______________Must be from the same office or practice
List Names for each additional attendee:________________________________________________________________
Total Enclosed $_____________
• Four Day Program Breast (Thur/Fri) & Musculo-Skeletal/Pain
(Sat/Sun)
Initial Attendee $3,400.00 $______________
Additional Attendee(s) $1,500.00 X ___ $______________Must be from the same office or practice
List Names for each additional attendee:________________________________________________________________
Total Enclosed $_____________
Total Enclosed $_____________
Please make out to: Dr William
Cockburn
Fax these two pages to: Dr William Cockburn (562)
695-2439 for scheduling
Mail Payment to: Dr William Cockburn
PO Box 2382 Whittier,
California 90610-2382
ACADEMY of MEDICAL
INFRARED TRAINING
ThermoDoc® Network
REGISTRATION FORM
Po Box 2382
Whittier, CA 90610-2382
(562) 699-7921 Fax- (562) 695-2439
Your
Instructor:
Dr
William Cockburn has been in private practice since 1975 and was first Board
Certified in Clinical Thermal Imaging in 1985. He is also Board Certified in
Radiology, Workers Compensation Law and Disability Evaluation. Dr Cockburn
maintains two thermal imaging practices in the greater Los Angeles area. Having
been Boarded by the CTS, ITS, IACT, AMII, Dr Cockburn brings a wealth of
Educational, Practice and Management experience to the clinician student.
This program is regularly updated and has been taught since 1999.
Location:
Los Angeles Area - California
Location to be determine based on class size
If you have any problems, please call Dr Cockburn at (562) 699-7921 Office
thermodoc@verizon.net